What Cancer Centers Need to Know about the Changing CoC Accreditation Standards
November 19, 2019
Areas of biggest impact:
Personnel/Services Resources and Patient Care Expectations
The Commission on Cancer recently released changes to its accreditation standards, a move that is expected to impact accredited facilities in the year 2020. It’s important that every cancer program administrator understands these changes, whether your facility is currently accredited or is considering pursuing accreditation in the next couple of years. As stated on the American College of Surgeons (ACS) webinar yesterday, the purpose of this update was to begin to align all of the ACS Quality Programs to ensure a common experience across the entire spectrum of care.
The OncoLens team of experts has poured over the new standards and put together a high-level comparison of some of the most significant changes that have been made. It is not our intention to provide guidance on how to modify your current operations to meet these guidelines, but to simply make you aware of them.
OncoLens has helped more than 2800 cancer care providers and staff dramatically reduce the amount of time and resources spent on attaining and/or maintaining CoC, NAPBC and NAPRC accreditation every year. We are currently in the process of incorporating these new requirements into our cancer treatment planning solution and many of the newly required data elements will be captured automatically in the OncoLens tumor board and survivorship care planning and reporting modules.
Most OncoLens customers have been able to cut accreditation report preparation time by 90%. Learn more about how OncoLens can help your cancer center adapt to the 2020 CoC accreditation standards by emailing us for more information at email@example.com.
Changes across nine domains can be found in the updated CoC accreditation manual. For a detailed view of the changes, cancer center administrators are encouraged to visit the CoC 2020 Standards website. The key changes highlighted by the OncoLens team are listed below and are focused on Domain 4 (Personnel and Services Resources) and Domain 5 (Patient Care: Expectations and Protocols).
A review of some differences between CoC’s 2016 and 2020 standards
2016 1.1 Physician Credentials
All physicians involved in the evaluation and management of cancer patients, as well as those serving in a required physician position on the cancer committee must be one of the following:
• Board certified; or
• In the process of becoming board certified, and
• Demonstrate ongoing cancer-related education by earning 12 cancer-related continuing medical education (CME) hours each calendar year. A maximum of six of the 12 hours can be earned through educational activities offered by the facility; however, all 12 hours can be earned through educational activities that are external to the facility.
2020 4.1 Physician Credentials
Cancer patient management is conducted by a multidisciplinary team, including radiologists, pathologists, surgeons, radiation oncologists, and medical oncologists. All physicians involved in the evaluation and management of cancer patients must:
• Be American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) board certified (or the equivalent), or
• Demonstrate ongoing cancer-related education by earning 12 cancer-related Continuing Medical Education (CME) hours each calendar year
2016 2.2 Oncology Nursing Care
Annual nursing competency evaluation of oncology knowledge and skills is completed and documented according to organizational policy, is approved by the cancer committee, and is documented in the cancer committee minutes. Oncology nursing certification for all nurses providing oncology care is strongly encouraged. All nurses who administer chemotherapy to patients need documented certification of chemotherapy training for both in-patient and out-patient units.
2020 4.2 Oncology Nursing Credentials
All registered nurses and advanced practice nurses providing direct oncology care must demonstrate one of the following:
• Current cancer-specific certification in the nurse’s specialty by an accredited certification program, or
• Ongoing education by earning 36 cancer-related continuing education nursing contact hours each accreditation cycle
2016 1.11 Cancer Registry Education
2016 5.1 Cancer Registrar Credentials
Each calendar year, all members of the cancer registry staff participate in one cancer-related educational activity applicable to their role.
Case abstracting is performed by a Certified Tumor Registrar.
2020 4.3 Cancer Registry Staff Credentials
Each calendar year, members of the cancer registry staff who do not hold a CTR credential must demonstrate completion of three hours of cancer-related continuing education applicable to their roles.
2016 2.3 Genetic Counseling and Risk Assessment
Cancer risk assessment, genetic counseling, and genetic testing services are provided to patients either on-site or by referral to a qualified genetics professional.
The cancer committee will monitor, evaluate, and make recommendations for improvements, as needed, cancer risk assessment, genetic counseling, and genetic testing and/or referrals annually and document in the cancer committee minutes.
2020 4.4 Genetic Counseling and Risk Assessment
While it is expected that programs provide genetics assessment for all relevant cancers on an on-going basis, each calendar year programs must identify a process pursuant to evidence-based national guidelines for genetic assessment for a specific cancer site.
The cancer committee must review and document in the minutes:
• The number of patients identified as needing referrals for the selected cancer site each year, and
• How many patients identified as needing referrals for the selected cancer site received a referral for genetic counseling
It is encouraged, but not required, that programs track whether patients who received referrals ultimately had genetic counseling
2016 2.4 Palliative Care Services
Palliative care services are available to patients either on-site or by referral.
The cancer committee will monitor, evaluate, and make recommendations for improvements, as needed, to palliative care services and/or referrals annually and document in the cancer committee minutes.
2020 4.5 Palliative Care Services
Each calendar year, the cancer committee monitors, evaluates, and makes recommendations for improvements to palliative care services. The evaluation is documented in the cancer committee minutes. During this evaluation, the cancer committee must:
• Assess the approximate number of cancer patients referred for palliative care services and for what services or resources
• Discuss the criteria utilized to trigger referrals to palliative care services
• Discuss areas of improvement – Examples include, but are not limited to, barriers to access of palliative care services, addition of palliative care services, decreasing emergency department usage, or improving the timeliness of referrals.
2016 ER 11 Rehabilitation Services
Policies and procedures are in place to ensure patient access to rehabilitation services either on-site or by referral.
2020 4.6 Rehabilitation Care Services
Each calendar year, the cancer committee must monitor, evaluate, and make recommendations for improvements, as needed, to rehabilitation care services and/or referrals. The content of the review and any recommendations for improvement are documented in the cancer committee minutes.
2016 ER 12 Nutrition Services
Policies and procedures are in place to ensure patient access to nutrition services either on-site or by referral.
2020 4.7 Oncology Nutrition Services
Each calendar year, the cancer committee must monitor, evaluate, and make recommendations for improvements to on-site oncology nutrition and hydration services and/ or referral services. The content of the review and any recommendations for improvement are documented in the cancer committee minutes.
2016 3.3 Survivorship Care Plan
The cancer committee develops and implements a process to disseminate a treatment summary and follow-up plan to patients who have completed cancer treatment.
End of 2018 and on: Provide SCPs to 50 percent of eligible patients who have completed treatment.
2020 4.8 Survivorship Care Plan
The cancer committee appoints a coordinator of the survivorship program per the requirements in Standard 2.1: Cancer Committee.
The Survivorship Program Coordinator develops a survivorship program team. Suggested specialties include physicians, advanced practice providers, nurses, social workers, nutritionists, physical therapists, and other allied health professionals.
The survivorship program team determines a list of services and programs, offered on-site or by referral, that address the needs of cancer survivors. The team formally documents a minimum of three services offered each year. Services may be continued year to year, but it is expected that cancer programs will strive to enhance existing services over time and develop new services.
Each year, the survivorship program coordinator gives a report, and the cancer committee reviews the activities of the survivorship program. The report includes: • An estimate of the number of cancer patients who participated in the three identified services • Identification of the resources needed to improve the services if barriers were encountered
Programs must demonstrate compliance by 1/1/2021
2016 2.1 College of American Pathologists Protocols and Synoptic Reporting
Each calendar year, 95 percent of the eligible cancer pathology contain all required data elements of the College of American Pathologists (CAP) protocols and are structured using the synoptic reporting format as defined by the CAP Cancer Committee.
For CoC-accredited programs, the CAP protocols apply to the following:
• Pathology reports created by the program from resected specimens with a diagnosis of invasive cancer.
• Pathology reports created by the program from resected specimens with a diagnosis of ductal carcinoma in situ (DCIS). Diagnostic biopsy specimens, cytology specimens, special studies, and reports of carcinoma in situ (except for ductal carcinoma in situ) are excluded.
At a minimum, a random sample of 10 percent of pathology reports eligible for the CAP protocols or a maximum of 300 cases are reviewed each year to document compliance with this standard. The cancer committee may delegate the quality control activity to a pathologist who will report the quality control activity and a summary of the findings annually to the cancer committee.
2020 5.1 College of American Pathologists Synoptic Reporting
Ninety percent of the eligible cancer pathology reports are structured using synoptic reporting format as defined by the College of American Pathologists (CAP) cancer protocols, including containing all core data elements within the synoptic format.
For CoC-accredited programs, “eligible cancer pathology reports” are defined as: • Definitive surgical resection of primary invasive malignancies and ductal carcinoma in situ (DCIS), and • Definitive surgical resection in patients who have received neoadjuvant therapy AND who have residual tumor.
2016 3.2 Psychosocial Distress Screening and
2016 ER10 Psychosocial Services
Cancer programs must develop a process to incorporate the screening of distress into the standard care of oncology patients.
All cancer patients must be screened for distress a minimum of one time at a pivotal medical visit as determined by the program.
Policies and procedures are in place to ensure patient access to psychosocial services either on-site or by referral.
2020 5.2: Psychosocial Distress Screening
Psychosocial services are available on-site or by referral.
Cancer patients are screened for psychosocial distress at least once during the first course of treatment.
The following patients are not included in compliance for this standard:
• Biopsy only or class of case “00” patients
• Patients who are admitted to the hospital with a history of cancer, but for non-cancer related issues
• Inpatients with a current diagnosis of cancer who are treated for a non-cancer issue and do not receive cancer treatment
2020 5.3 Breast Sentinel Node Biopsy
All sentinel nodes for breast cancer are identified, removed, and subjected to pathologic analysis.
Operative reports for patients undergoing breast sentinel node biopsy includes required minimum elements in synoptic format.
2020 5.4 Breast Axillary Dissection
Axillary dissections for breast cancer remove level I and II lymph nodes within an anatomic triangle comprised of the axillary vein, chest wall, and latissimus dorsi, while preserving key neurovascular structures.
Operative reports for patients undergoing axillary dissection include the required minimum elements in synoptic format.
2020 5.5 Primary Cutaneous Melanoma
This standard applies to patients undergoing curative-intent wide local excision of a primary cutaneous melanoma lesion.
Clinical margin width for wide local excision of invasive melanoma is 1 cm for melanomas less than 1 mm thick.
Clinical margin width for wide local excision of invasive melanoma is 1 to 2 cm for melanomas 1 to 2 mm thick.
Clinical margin width for wide local excision of invasive melanoma is 2 cm for melanomas greater than 2 mm thick.
The clinical margin width for wide local excision of a melanoma in situ is at least 5 mm.
Operative reports for patients undergoing a wide local excision of a primary cutaneous melanoma include the required minimum elements in synoptic format.
2020 5.6 Colon Resection
This standard applies to all curative resections for colon cancer and applies to all operative approaches.
Resection of the tumor-bearing bowel segment and complete lymphadenectomy is performed en bloc with proximal vascular ligation at the origin of the primary feeding vessel(s).
Operative reports for patients undergoing resection for colon cancer include the required minimum elements in synoptic format.
2020 5.7 Total Mesorectal Excision
This standard applies to operations for curative intent radical resections of rectal adenocarcinoma and excludes local excision approaches.
Total mesorectal excision is performed for all patients undergoing radical surgical resection of mid and low rectal cancers and results in a complete or near complete mesorectal excision.
The quality of TME resection (complete, near complete, or incomplete) is documented in curative resection of rectal adenocarcinoma pathology reports in synoptic format.
2020 5.8 Pulmonary Resection
This standard applies to the primary surgical procedure for curative intent pulmonary resections for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), and carcinoid tumors of the lung. This standard applies to all operative approaches.
The surgical pathology report following any curative intent pulmonary resection for primary lung malignancy must contain lymph nodes from at least one (named and/ or numbered) hilar station and at least three distinct (named and/or numbered) mediastinal stations.
The nodal stations examined by the pathologist must be documented in curative pulmonary resection pathology reports in synoptic format
There are several standards that will be phased in over the coming years. These standards are more clinical in nature, and therefore the CoC will give facilities more time to study these standards and work toward implementation over time. They mainly center around cancer surgeries for certain disease sites, oncology nursing credentials, and also survivorship care planning. Administrators are encouraged to work collaboratively with their surgeons and hospital staff to introduce these new standards at their facility and the ACS will continue to provide education sessions on the new requirements.
OncoLens is preparing a more comprehensive webinar for the industry and plans to discuss how its platform can assist cancer centers with CoC, NAPBC, and NAPRC accreditation. Registration will be opening soon so watch our blog and social media posts for notification of the date and time!